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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 114-116

Well-planned successful tracheostomy tube change in a child


1 Department of Anaesthesia, Critical Care and Pain, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Head and Neck Surgical Oncology, Critical Care and Pain, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Submission12-May-2021
Date of Acceptance04-Jun-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Unnathi Purushotham Manampadi
Department of Anaesthesia, Critical Care and Pain, Homi Bhabha National Institute, Tata Memorial Hospital, Dr E. Borges Road, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/arwy.arwy_28_21

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  Abstract 


Paediatric tracheostomy and tracheostomy tube change are associated with a higher incidence of adverse events that need to be recognised, mandating thorough evaluation and meticulous planning to avert such events. In addition, implementation of standard guidelines in every institute is necessary to maintain optimum safety. We report the successful management of a difficult paediatric tracheostomy tube change in a 3-year-old boy who had a history of failure of tracheostomy tube change in the ward 1 month following the initial tracheostomy. The initial attempt of changing the tube to secure the airway was unsuccessful. As difficulty in tube exchange was anticipated, we were able to secure the airway with endotracheal tube loaded on to a paediatric fibreoptic bronchoscope which was already positioned in the trachea. We believe that a well-planned management strategy executed in a monitored and well-equipped surrounding helped in avoiding grave consequences.

Keywords: Difficult paediatric airway, fibreoptic bronchoscope, paediatric tracheostomy tube change


How to cite this article:
Manampadi UP, Bakshi SG, Salunke B, Thiagarajan S. Well-planned successful tracheostomy tube change in a child. Airway 2021;4:114-6

How to cite this URL:
Manampadi UP, Bakshi SG, Salunke B, Thiagarajan S. Well-planned successful tracheostomy tube change in a child. Airway [serial online] 2021 [cited 2021 Dec 2];4:114-6. Available from: https://www.arwy.org/text.asp?2021/4/2/114/323573




  Introduction Top


Paediatric tracheostomy is associated with a higher incidence of adverse events.[1] Between 15% and 19% of children experience a tracheostomy-related complication.[2] The most common tracheostomy-related cause of death in children has been reported to be tube obstruction, followed by tube misplacement and accidental decannulation.[1] Changing the tracheostomy tube is a crucial procedure done after tracheostomy.[3] It is essential to understand the procedure and anticipate possible problems. We report the successful management of an anticipated difficult tracheostomy tube change in a child, a postoperative case of posterior fossa anaplastic ependymoma.


  Case Report Top


A 3-year-old male child, a diagnosed case of posterior fossa anaplastic ependymoma, underwent suboccipital craniotomy and total resection of the tumour. He had a history of prolonged stay in the postoperative intensive care unit in view of postoperative meningitis and ventilator-associated pneumonia. Due to residual cranial nerve palsy, it was decided against decannulation of the tracheostomy tube. The child also suffered from an acute coronary event with reduced ejection fraction and global hypokinesia during his stay in the ICU. He was diagnosed to have incomplete Kawasaki disease for which he was started on aspirin, clopidogrel and metoprolol. The drugs were stopped after a month.

The child had a history of failure of tracheostomy tube exchange attempted in the ward due to blockage of tube with drop in saturation 1 month after the initial tracheostomy. The child had documented hypoxia and bradycardia during this tracheostomy tube exchange. The airway had to be secured by an orotracheal tube. A cuffed tracheostomy tube (4.0 mm ID) was reinserted in the operative room and the child was discharged from the hospital.

On routine follow-up, the pilot balloon of the tracheostomy tube was found to be stiff and non-compliant. An attempt was made to change the tube, but there was resistance while withdrawing the tracheostomy tube. The procedure was deferred in the outpatient department and the child was posted for tracheostomy tube change in the day-care operation theatre (OT) complex. On examination, the child was conscious with a Glasgow Coma Score of 10 (E4M6VT) with a cuffed tracheostomy tube in situ. The child was malnourished (body weight of 10 kg), maintaining saturation of 98% on room air. On auscultation, the chest was clear and other vital parameters were normal.

A detailed airway management plan was formulated by the surgical and anaesthetic team. All equipment was kept ready including a paediatric videolaryngoscope, fibreoptic bronchoscope and rigid bronchoscope. The child was taken into the OT and monitors were attached. After confirming good air movement through the tracheostomy tube, the child was oxygenated before the procedure until the end-tidal oxygen was more than 90%. Inhalational induction with sevoflurane was then initiated. Once the child was under anaesthesia, a 24 SWG intravenous cannula was secured and injection propofol 10 mg along with injection succinylcholine 10 mg was given. The child was paralysed with subsequent doses of injection succinylcholine 1 mg/kg after giving injection atropine 0.01 mg/kg. A 4 mm OD paediatric fibreoptic bronchoscope (Karl Storz paediatric flexible intubation video-endoscope) was preloaded with a 4 mm ID Microcuff endotracheal tube (Halyard Microcuff paediatric endotracheal tube) and was inserted transorally into the trachea. The tip of the fibrescope was placed above the tracheostomy tube that was in situ and the presence of any granulation tissue around the tube was ruled out [Figure 1]. An attempt was made to remove the tracheostomy tube under vision over a suction catheter. A 3.5 mm ID cuffed polyvinyl chloride tracheostomy tube was now railroaded over the suction catheter with difficulty. However, the paediatric fibreoptic scope already positioned in the trachea failed to visualise the tube suggesting its entry into a false passage. The tracheostomy tube was removed. Soon after, the saturation dropped to 92% and the airway was secured by advancing the endotracheal tube preloaded onto the fibreoptic scope and placed just above the site of the tracheostomy. The lungs were ventilated till saturation came up to 100%. Anaesthesia was maintained throughout using intermittent boluses of propofol and succinylcholine as indicated. The second successful attempt was done by performing a cruciate incision around the stoma followed by tracheal dilation and bougie-guided insertion of a 3.5 mm ID cuffed tracheostomy tube. The correct position of the tracheostomy tube was confirmed by capnographic waveform and visualisation of the tracheostomy tube through the fibreoptic scope. Vital parameters were stable throughout the procedure and the child was shifted to the recovery room for observation.
Figure 1: View through a paediatric bronchoscope placed above the level of the tracheostomy tube confirming absence of any obvious reason such as granulation tissue that could pose a difficulty in tracheostomy tube change

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  Discussion Top


In children, tracheostomy care is a complex multidisciplinary process.[3] Routine maintenance for tracheostomy involves periodic cleaning of the tube and stomal care, monitoring of cuff pressure and adequate humidification.[4] Indications for a tracheostomy tube change are minimising the risk of infection and formation of granulation tissue, decannulation process and verifying the formation of a mature tract.[4] There have been many single-institution reports in adult literature addressing tracheostomy care. Unfortunately, there is insufficient standardisation of protocols and policies for paediatric population regarding tracheostomy care.[1]

It generally takes 7 days postprocedure for maturation of the tracheostomy tract.[4] A retrospective case study conducted by Deutsch suggested that a much shorter time of tube change might be reasonable, as it was found to be safe and advantageous in facilitating better hygiene, earlier completion of family caregiver tracheotomy education and shorter duration of hospital stay.[5] Due to the lack of standard recommendations for tracheostomy tube change, many institutions and hospitals have implemented a local protocol or guideline for improving outcomes. The National Tracheostomy Safety Project (United Kingdom) is a nationwide initiative which has a team dedicated to looking after patients with tracheostomy tubes comprising otolaryngologists, anaesthesiologists, chest physicians, specialist nurses, speech and language therapists and respiratory therapists aimed at improving the care of patients with tracheostomy.[4]

In this case, the event following the first tracheostomy tube change in the ward was probably due to the tube slipping into the false passage which is a common complication encountered during the procedure.[4] It has been observed that an initial tube change in general wards is associated with a higher risk of airway loss in comparison to the ones done in intensive care units or step-down care units (96.1% vs. 63.6%).[6] This prompted us to perform the tracheostomy tube change in the minor OT complex. Despite all care, the tracheostomy tube slipped into a false passage during the procedure, but an endotracheal tube preplaced in the trachea transorally helped in establishing effective ventilation. In children, hypoxia leading to bradycardia is common, and hence, it is necessary to have a feasible back-up plan.[7] In this case, the tracheostomy tube change in a well-equipped and monitored surrounding helped in averting complications. We conclude that tracheostomy tube change in paediatric population mandates a thorough evaluation and meticulous planning to avert adverse events. In addition, standard guidelines and protocols need to be implemented in every institution to maintain optimum safety and quality of care.

Declaration of patient consent

The authors certify that they have obtained the appropriate patient consent form. In the form, the parent of the child has given consent for images and other clinical information to be reported. The parent understands that the name and initials of the child will not be revealed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Watters KF. Tracheostomy in infants and children. Respir Care 2017;62:799-825.  Back to cited text no. 1
    
2.
Berry JG, Graham DA, Graham RJ, Zhou J, Putney HL, O'Brien JE, et al. Predictors of clinical outcomes and hospital resource use of children after tracheotomy. Pediatrics 2009;124:563-72.  Back to cited text no. 2
    
3.
Speed L, Harding KE. Tracheostomy teams reduce total tracheostomy time and increase speaking valve use: A systematic review and meta-analysis. J Crit Care 2013;28:10.e1-10.  Back to cited text no. 3
    
4.
Ng J, Hamrang-Yousefi S, Agarwal A. Tracheostomy Tube Change. StatPearls. Treasure Island (FL): StatPearls Publishing; 2021.  Back to cited text no. 4
    
5.
Deutsch ES. Early tracheostomy tube change in children. Arch Otolaryngol Head Neck Surg 1998;124:1237-8.  Back to cited text no. 5
    
6.
Tabaee A, Lando T, Rickert S, Stewart MG, Kuhel WI. Practice patterns, safety, and rationale for tracheostomy tube changes: A survey of otolaryngology training programs. Laryngoscope 2007;117:573-6.  Back to cited text no. 6
    
7.
Gálvez JA, Acquah S, Ahumada L, Cai L, Polanski M, Wu L, et al. Hypoxemia, bradycardia, and multiple laryngoscopy attempts during anesthetic induction in infants: A single-center, retrospective study. Anesthesiology 2019;131:830-9.  Back to cited text no. 7
    


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